ROTATOR CUFF REPAIR
From Boston University School of Medicine’s Evaluation and Treatment of the Injured Athlete
| PARTIAL-THICKNESS ROTATOR CUFF TEARS AND PASTA LESIONS— Timothy E. Foster, MD, Assistant
Professor of Orthopaedic Surgery, and Co-Director of Sports Medicine, Boston University School of Medicine, Boston,
MA
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| Background: location—66% to 80% of partial-thickness rotator cuff tears occur on articular side (percentage even
higher among young athletes); incidence—unknown; estimated as twice that of full-thickness tears; imaging studies
reveal partial-thickness tears among asymptomatic throwing athletes; underreporting likely; associated pathology—
cadaver study found biceps lesions in 30% of shoulders with partial tear in subscapularis (ie, important to look for biceps
lesions in shoulders with subscapularis tears)
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| Classification: Neers—not helpful for partial-thickness tears of rotator cuff; Harvard Ellman—based on location
(bursal, articular, or interstitial) and depth; other lesions—partial articular supraspinatus tendon avulsion (PASTA);
partial articular tears with intratendinous extension (PAINT); Boston University system—based on location, extent of
tear, and etiology
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| Diagnosis: determine whether pain caused by tear or by other pathology (eg, biceps tendon, acromioclavicular [AC]
joint); positive response to lidocaine challenge suggests pain caused by tear; imaging—plain radiographs rarely
have positive findings; presence of greater tuberosity notch suggests partial tear on articular side; acromial morphology
visible; magnetic resonance imaging (MRI) and magnetic resonance angiography (MRA) more useful;
MRA preferred for patients with suspected partial tear on articular side; ultrasonography has high sensitivity and
specificity but requires experienced technician
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| Nonoperative treatment: nonsteroidal anti-inflammatory drugs (NSAIDs); physical therapy, including stretching
of posterior capsule; subacromial injections of corticosteroids associated with decreases in growth factors (consider
avoiding if surgery likely); throwing athletes—targets for treatment include scapula and posterior capsule, joint instability,
and mechanics; surgery considered if nonoperative treatment unsuccessful after 3 to 6 mo
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| Progression: partial tears may progress to full-thickness tears; debridement does not appear to reverse degeneration
of tendon; no histologic evidence that tendon heals; small study found progression in 80% of articular-side tears
when followed for 2 yr
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| Surgery: no good studies comparing outcomes from open and arthroscopic approaches; debridement—place spindle
needle in defect; mark tear with polydioxanone (PDS) suture; inspect bursal side; debride extent of partial tear;
consider subacromial decompression; when to repair—historically, repair performed for tears that span ≥50% of
tendon or result in 50% liftoff of footprint; some authors recommend repairing smaller tears; transtendinous
repair—intact fibers of bursal side preserved; technique used for articular-side tears; metal suture anchor set
through defect into footprint; good outcomes reported, but taking large portion of tissue constrains joint; completion
of tear—complete tear using knife or elevator; repair tear to tuberosity with single or double row of anchors; debride
damaged tissue, even if intact (removes source of pain); outcomes—no randomized controlled trials or long-
term follow-up studies have followed outcomes of nonoperative therapies; 89% of patients who undergo debridement
alone have good to excellent results (but risk for progression over time); in case series of debridement with
decompression, incidence of good to excellent results 84% and 76%, but not recommended for bursal-side tears; in
athletes, outcomes better after acute traumatic injury (86% satisfactory) than after insidious onset (64% satisfactory);
46% to 66% of athletes return to sports after injury; no long-term studies have followed outcomes after surgical
repair; available studies report good to excellent results in ≈90% of patients
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| ARTHROSCOPIC SUBSCAPULARIS REPAIRS —Sumant G. Krishnan, MD, Clinical Assistant Professor, University
of Texas Southwestern Medical Center, and Attending Orthopaedic Surgeon, Shoulder and Elbow Service,
WB Carrell Memorial Clinic, Dallas, TX
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| Background: suprascapular neuropathy may cause pain and weakness in shoulder; patients with massive tears of
rotator cuff or acute extension of chronic tear at increased risk for suprascapular neuropathy and failure of repair;
electromyography (EMG) studies show 30% to 50% decrease in velocity of neural conduction across transverse
scapular notch and suprascapular ligament among patients with 2-tendon tears with acute extensions; lateral approach
to repair—requires extensive dissection to identify suprascapular nerve; technically difficult
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| Iatrogenic suprascapular neuropathy: repairing massive tears changes length-tension relationship of myomeres
and position of suprascapular nerve; repair may lead to suprascapular neuropathy
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| Anterior approach to arthroscopic repair: position—beach chair or modified beach chair (orienting acromion
parallel to floor); portals—“safe-side,” ie, classic anterior portal, halfway between coracoid and acromion; “suicide”
portal along medial border of coracoid (through muscle belly of pectoralis major); classic posterior, lateral,
posterolateral, and anterolateral portals; no portals along acromial margin; inflammation—isolated suprascapular
neuropathy causes acromiohumeral inflammatory response; decompression completed using ablation device;
orientation—flex shoulder 30° to open anterosuperior bursa (facilitates identification of coracoid process [very
reproducible landmark, aka, “lighthouse of shoulder”]); follow medial border of coracoid to suprascapular nerve,
where it exits upper trunk of brachial plexus; no dissection required; blunt trocar may be used to strip posteromedial
edge of bursa; follow nerve to suprascapular notch (beneath transverse scapular ligament); access suprascapular
nerve vertically from notch portal (2 cm medial to posterior border of AC joint); release ligament; allow nerve
to guide decompression, medial to lateral; evaluate anatomy of notch (may be partly responsible for lesion); decompress
notch using shaver or burr
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 | Advantages: avoids suprascapular artery and reduces risk of damaging nerve
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| Outcomes: case series of isolated nerve release in 17 patients and nerve release combined with repair of rotator cuff
in 22 patients showed no neurovascular complications; mean operative time for nerve release, <15 min
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| SURGICAL ESSENTIALS OF ROTATOR CUFF ANATOMY AND TEARS —Robert E. Hunter, MD, Professor,
Clinical Orthopaedic Surgery, Director, Division of Sports Medicine, University of Arizona, College of Medicine,
and Director, Arizona Institute for Sports Medicine, Tucson
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| Shoulder arthroscopy: necessary skills—perform diagnostic intra-articular and subacromial examination; perform
subacromial decompression and distal clavicle resection; probe and evaluate rotator cuff (assess tear); repair superior
labral anterior and posterior (SLAP) tear and Bankart lesion
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| Knot tying: learn several knots well; non-sliding knot—eg, double half-hitch; mandatory if suture does not slide
through anchor; post—suture around which knot is tied and slid down; placement determines location of knot; double
half-hitch (square knot)—overhand half-hitch followed by underhand half-hitch (combining overhand and underhand
throws especially important in arthroplastic procedures); consistency critical; securing (“dressing”) sliding knots—reinforce
and lock to prevent sliding; reverse post twice (eg, left hand to right hand to left hand); reverse throw twice
(eg, overhand, underhand, overhand); Tennessee slider—short post limb; knot may be thrown without letting go of
suture; applying too much tension locks knot prematurely; corrections made before knot enters cannula; 3 overhand
half-hitches used to adjust tension; knot secured as described above (will appear tangled when done correctly)
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| Knot pusher technique: practice skills in lab (consistent technique important); control device with one hand; use index
and middle fingers as triggers to “piston” in and out of cannula; advantages—manipulates and controls placement
of knot without need for hemostats or assistant; pearls—begin with long suture (short post); keep knot pusher
ahead of knot; pull knot through cannula to desired location
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| Anchor insertion and orientation: various anchors available, each with different markings that indicate orientation;
anterior-to-posterior orientation of eyelet allows both limbs (anterior and posterior) to slide through anchor;
goal—achieve lateral fixation of cuff, stabilize joint, and provide adequate spacing; tension—created by grabbing
and pulling wrong part of cuff or by grabbing bites of different length and direction; uneven tension may cause repair
to fail
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| Suture management: store sutures outside of work area (“stay out of your own way”); insert sutures far to near,
then tie near to far (avoid working over untied sutures); portals—nonstandard position of posterior portal (closer
to acromion and lateral of standard position); working portal; spinal needle used to create anterior portal; fourth
portal, midway between posterior and lateral portals, provides lateral view of cuff; all cannulae and instruments
point directly to tear
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| Suture passage: punch and shuttle—ie, Caspari punch; no longer used; pierce and grab—pierce cuff with instrument
and grab suture off anchor (2-handed maneuver; assistant holds arthroscope); watch for movement through anchor
while retrieving suture (no movement should occur when free limb pulled); pierce and carry—good for small tears
at end of repair; grab suture and load into shuttling device; pierce and shuttle—good technique to use inside joint;
number 1 monofilament suture (eg, PDS) may be used in place of shuttling device; position monofilament and make
loop; pass braided suture through loop and tighten; pull monofilament through cuff (carries braided suture)
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| Preparation and planning: work with equipment companies that provide training; write out step-by-step procedure;
begin with simple cases; use mini-open technique if necessary (extend lateral portal; work through anterior and
posterior cannulae, using arthroscopic equipment; tie knots using arthroscopic technique); mastering technique—
begin with boards and models; take focused course; work with experts
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| THE IRREPARABLE ROTATOR CUFF TEAR —Dr. Krishnan
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| Classification: based on size of tear and number of tendons involved; irreparable tear—refractory to multiple attempts
at repair; age—young patients with otherwise healthy tissue approached differently from older patients
with significant pathology
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| Physical examination: atrophy; lag signs and hornblower sign (patient unable to maintain maximum external rotation)
pathognomonic for massive tear of rotator cuff
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| Imaging: radiography—acromiohumeral interval visible on anteroposterior (AP) view; intervals <7 mm indicate irreparable
tear; acromial morphology; evidence of arthropathy (eg, central erosions, decreased joint space); MRI—
gold standard; permits evaluation of size of tear, number of tendons, and extent of atrophy, retraction, and migration;
hypertrophy of teres minor may occur (especially in patients with retained function); fatty infiltration graded based on
relative amounts of healthy muscle and fat; increased fatty infiltration (eg, stages 3 and 4; ≥50% fatty infiltration) increases
risk for failure of repair and poor functional outcome
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| Debridement and decompression: some authors report improved function; pain reduction primary goal
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| Biceps tenotomy or tenodesis: case series (Boileau, 2007) of 72 cases of irreparable rotator cuffs showed satisfaction
rate 78%; intact teres minor and ability to rotate shoulder externally associated with good outcome; no benefit
seen in patients with pseudoparalytic shoulders; forward elevation regained in some patients; biceps tenotomy
associated with risk for Popeye sign
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| Partial repair: loss of force-couple results in inability to contain humeral head in glenoid and loss of active forward
elevation; partial repair to reestablish force-couple (eg, repairing posterior infraspinatus) increases forward elevation
and improves symptoms
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| Muscle transfer: good option for young healthy patients with decreased forward elevation; latissimus dorsi transferred
to greater tuberosity; requires intact subscapularis; procedure—access latissimus dorsi tendon through incision
at axilla; internally rotate arm; detach tendon at insertion point; bluntly release and mobilize muscle; prepare
greater tuberosity for attachment; move latissimus underneath deltoid and reattach to greater tuberosity; augment
supraspinatus and local tissue to promote healing; outcomes—forward elevation restored in some patients with
pseudoparalysis; procedure generally recommended only after others (eg, debridement, partial repair) have failed;
EMG studies show activity in latissimus during adduction and isometric external rotation, but not always during
forward elevation; biofeedback and physical therapy important to retrain muscle
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| Free tissue grafts: cover bald humeral head; may cause inflammatory reaction
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| Rotator cuff arthropathy: proximal migration may occur with chronic massive rotator cuff tears, resulting in eccentric
loading of glenoid, loss of articular surface, and ultimately, glenohumeral arthritis; patients have pain, bony
crepitus, and loss of function; features include atrophy of supraspinatus and infraspinatus and acetabularization of
acromion and glenoid
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| Treatment options: nonoperative treatment (especially for less active, older patients); arthroscopy; biceps tenodesis;
arthrodesis (few indications); unconstrained total shoulder arthroplasty; hemiarthroplasty; constrained or
semiconstrained total shoulder replacement (unconstrained total shoulder replacement contraindicated in patients
with arthropathy due to rotator cuff tears); hemiarthroplasty without glenoid resurfacing (relieves pain; may not
improve function)
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| Semiconstrained and constrained shoulder arthroplasty: goal—maintain humeral head in glenoid to create fulcrum
for raising arm; reverse prosthesis adds tension to deltoid, constrains humerus, changes center of rotation (increases
mechanical advantage), and decreases moment arm (decreases risk of loosening); case—woman, 80 yr
of age, with pseudoparalytic shoulder, proximal migration, arthropathy, and loss of glenohumeral articulation;
procedure resulted in increased tensioning of deltoid and ability to raise arm; caution—many complications; not
indicated for everyone
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| Choice of procedure: limited repair or tendon transfer for young patient with pain, severe disability, and intact deltoid;
in older patients with pain, try nonoperative treatments first, then arthroscopic approaches in attempt at partial
repair; hemiarthroplasty for older patients with arthritis but good function; reverse prosthesis appropriate for
patients with pseudoparalysis
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Suggested Reading
Boileau P et al: Isolated arthroscopic biceps tenotomy or tenodesis improves symptoms in patients with massive irreparable
rotator cuff tears. J Bone Joint Surg Am 89:747, 2007; Cole BJ et al: Arthroscopic rotator cuff repairs: an anatomic
and biomechanical rationale for different suture-anchor repair configurations. Arthroscopy 23:662, 2007; Cole BJ
et al: Arthroscopic rotator cuff repair: prospective functional outcome and repair integrity at minimum 2-year follow-up.
J Shoulder Elbow Surg 16:579, 2007; Franceschie F et al: Equivalent clinical results of arthroscopic single-row and
double-row suture anchor repair for rotator cuff tears: a randomized controlled trial. Am J Sports Med 35:1254, 2007;
Goutallier D et al: Influence of cuff muscle fatty degeneration on anatomic and functional outcomes after single suture
of full-thickness tears. J Shoulder Elbow Surg 12:550:2003; Henn RF 3rd, et al: Patients’ preoperative expectations
predict the outcome of rotator cuff repair. J Bone Joint Surg Am 89:1913, 2007; Ho JY, Miller SL: Allografts in the
treatment of athletic injuries of the shoulder. Sports Med Arthrosc 15:149, 2007; Moser M et al: Functional outcome of
surgically treated massive rotator cuff tears: a comparison of complete repair, partial repair, and debridement. Orthopedics
30:479, 2007; Provencher MT et al: Arthroscopic versus open rotator interval closure: biomechanical evaluation of
stability and motion. Arthroscopy 23:583, 2007; Shen PH et al: Long-term functional outcomes after repair of rotator
cuff tears correlated with atrophy of the supraspinatus muscles on magnetic resonance images. J Shoulder Elbow Surg Oct
10, 2007 [Epub ahead of print]; Vitale MA et al: Training resources in arthroscopic rotator cuff repair. J Bone Joint
Surg Am 89:1393, 2007; Yoo JC et al: Arthroscopic full-layer repair of bursal-side partial thickness rotator cuff tears: a
small-window technique. Arthroscopy 23:903, 2007.
Educational Objectives
| The goal of this program is to improve outcomes of rotator cuff repair. After hearing and assimilating this program,
the clinician will be better able to:
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| 1. Diagnose partial-thickness rotator cuff tears and assess relationship to pain and function.
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| 2. Compare outcomes of surgical and nonsurgical repairs of partial-thickness tears of the rotator cuff.
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| 3. Describe the anterior approach to arthroscopic repair of subscapularis tears.
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| 4. Recall surgical pearls about arthroscopic techniques for rotator cuff repair.
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| 5. Identify irreparable tears of the rotator cuff and describe treatment options.
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Faculty Disclosure
In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty members to disclose
relevant financial relationships within the past 12 months that might create any personal conflicts of interest. Any
identified conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary
business or commercial interest. For this program, the following has been disclosed: Dr. Krishnan is a consultant
for and receives grant support from DePuy Miter and Tornier; Dr. Hunter holds a commercial interest in Smith
and Nephew.
Acknowledgments
Drs. Foster, Krishnan, and Hunter were recorded at Evaluation and Treatment of the Injured Athlete, sponsored by Boston
University School of Medicine, and held July 30 to August 3, 2007, in Boston, MA. The Audio-Digest Foundation
thanks the speakers and Boston University School of Medicine for their cooperation in the production of this program.
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